Tuesday, August 30, 2011

Should I stay or should I go? A real mid-life crisis

It was like taking a ride in a time machine.

I had the chance, last week, to meet the incoming class of medical students at the University of Saskatchewan.  Just over 30 years ago, I sat where they were sitting, likewise listening to some old-timer blather on about what he had done during his career and what I had to look forward to.  

At that point, I hadn't yet examined a patient, written a prescription, or even taken an anatomy class.  In retrospect, I had no idea what I was getting into.  I was thrilled to be in the class, yet totally bewildered.  I recognized the same look on some of the faces of these new medical students.

I felt a mid-life crisis well up.

I've joked about mid-life crisis before, but I think I'm beginning to appreciate what it's really all about.  I've been practicing urology for almost 20 years.   That means I'm beyond the half-way point of my surgical career.  My upcoming birthday is a noteworthy one, in an over-the-hill way.  So, I've been thinking a lot lately about what I should be doing with the 2nd half of my career.  The topic I was addressing with the students only fueled my angst.

I was part of a panel discussion about physician leader and civic professionalism.  Our group included 2 practicing physicians (myself included), a physician administrator, a resident and a 3rd year medical student.  The course instructor had asked us to reflect on our own leadership experiences - why we took leadership roles, what we found satisfying about them, and what challenges physician leaders face.

I confessed that I spent my time in medical school, and the first 10 years of my practice, actively avoiding these roles.  In fact, one of the first leadership positions I took on was our office's Advanced Access/Clinical Practice Redesign work - the same work you've seen documented in this blog for the last 4 years.  That experience has taught me a lot about leadership, and encouraged me to seek out further leadership training and opportunities.  The other panel members related similar stories.

Giving the positive side of leadership work is easy and fun. And misleading.  Being a physician leader is hard work.  There are a lot of barriers to success, and talking about those reminded me of the questions I've been struggling with about my career’s direction.

Physician leaders are not readily recognized and valued for the work they do.  Brent Thoma, the ER resident on the panel, made this point when he spoke about his own experience as a class leader during medical school.  He pointed out that there are many scholarships for students who excel academically.  Top students in basic and clinical sciences receive recognition and rewards.  But, other students who choose to spend some of their valuable time in organizing class gatherings, charity fundraisers or the provision of healthcare to under-serviced communities don't get the same acknowledgement.  He was pleased to report that the College of Medicine had a new scholarship for such medical student leaders.

It's not any easier for practicing physicians.  First and foremost, doctors value clinical work, followed by teaching and research.  Administration and leadership are often  look upon with distain.  "He's gone over to the Dark Side" is a common jibe.  

Also, many physicians take a pay cut if they sacrifice clinical work to take on leadership roles.  For other health professions, an administrative/leadership role might mean greater opportunity for career advancement, with increased compensation and status. That's usually not the case for physicians.

Physicians have often been thrust into leadership roles without adequate preparation.   Until recently, leadership training was not a part of the formal medical school curriculum.  In the same way that doctors starting medical practice are presumed (by virtue of their doctor-ness) to be competent to teach medical students, they are presumed to be naturally competent leaders.  This assumption leads to uninspiring results for the healthcare system, and frustration and discouragement for the unprepared physician leader.

After the panel discussion, all these impediments to physician leadership were swirling inside my head, only to be accentuated by my reading, later that day, Andre Picard's interview with outgoing CMA president, Jeff Turnbull.  The piece's title, When even Dr. Optimism is losing faith in medicare, it's time to fix it, tells the story. Turnbull reports his frustration with "the lack of leadership, co-ordinated management, accountability and responsibility and, yes, needless waste.  Worse, we allow staggering inefficiency, ineffective management processes, incoherent decision-making and practice variations that undermine quality and safety."

While Turnbull insists that he remains optimistic, imagine what resolve it must take to maintain that outlook, given the dysfunction he has seen at every level of healthcare, from the highest level of health policy to individual patient care.

Turnbull's sentiments, while on a grander scale, are similar to mine as I've been trying to decide what direction to take.  While the leadership work I've undertaken so far has been very rewarding, it can be stressful, and takes me away from the clinical work that I also enjoy.  Improvement projects never seem to move as quickly as I would like.  

It would be so much easier to keep my head down and retreat to the familiar trenches of clinical practice.  After 20 years, there’s a comfortable level of competence.  While there’s enough variety and challenge to keep things stimulating, the learning curve has flattened.  I have a great group of partners and staff to work with.  I could give up the meetings and committees and projects.  I could be home for supper more reliably.  And, the money is good.  Great, actually.

It’s a little disturbing to acknowledge the allure of the familiar ground of clinical medicine.

The question I’ve been asking myself is: Why fight it? Why not give up leadership work? 

I think I have the answer:  Medical leadership is not separate from clinical practice; it is an extension of clinical practice.  The will to lead flows from the desire to bring about change.  Once I understood that changing only my own practice severely limited the improvement my patients could experience, I was compelled to try to influence change beyond each single physician-patient encounter.

Experiencing, on a daily basis, the frustrations that Dr. Turnbull described, fuels my will to change things.  But, I don’t intend to change The System - that amorphous, slippery, anonymous, maddening thing.  I don’t think I can change that.

But, people made The System, and they – we - remake it everyday.  I think I can help, convince and cajole people (and myself!) to work differently, and through collective effort, we can replace The System with something we will be proud to be part of.

There’s great joy in that.

And so, crisis resolved. 

I'm turning 50, and I’m not turning back.

Sunday, August 21, 2011

Safety deserves more than lip service

Earlier this month, my family and I flew home after a holiday in Newfoundland.  As we boarded the flight in Deer Lake, my 2 sons led the way onto the plane and took the first two seats we had been assigned.  Unfortunately, their seats were in the exit row and, as they were too young to sit there, we moved them to our other assigned seats.  My wife and I took the exit row seats.

The flight attendant arrived to give the exit row passengers instructions on how to open the emergency exit in case of the need to evacuate the airplane.

"Pull down the handle, pull the door inward, then throw it clear outside the airplane.  Are you OK with that?"

She looked expectantly at me and my wife.  I hesitated.

Before the flight attendant had arrived to brief us, I had noticed that the opposite exit row window seat was occupied by an elderly lady, perhaps in her late 70's, and very slightly built.  The emergency exit instructions noted that the door weighed 40 pounds.  I thought it was unlikely that this lady would be able to manhandle a 40-pound door.

The flight attendant was waiting for my reply.

"Are you OK with that," she repeated.

I was unsure what to say.  My wife and I could certainly handle our exit, but I was convinced that the lady opposite couldn't.  Was it any of my business to point this out?  Surely the flight attendant could see the same problem that I did.  Perhaps I was overreacting.  After all, she must have been trained to assess a passenger's ability to help in case of an emergency.

The easiest route would have been to nod my head and let her get on with departure preparations.  But, the situation was so obviously inappropriate, I couldn't let it go.  But, I was unsure how to proceed.  If I explicitly related my concern, I may offend or upset the elderly lady sitting across from me.  The flight attendant was already puzzled at my silence, and I certainly didn't want to upset her.  I tried to drop a hint.

"Well, I'm OK, but I'm not sure everyone else is..."

I glanced across the aisle, and she followed my gaze.  She took the hint.

Or, so I thought.

She caught the elderly lady's attention and asked her "Are you comfortable with that?"

"Oh, yes," was her reply.

I wasn't sure that the elderly passenger had actually understood what the flight attendant was asking her. The question was ambiguous and she may have simply been indicating that she was comfortable in her seat.

"Anyway," the flight attendant assured us, "It's extremely unlikely that we would need to evacuate."

The flight attendant was obviously uncomfortable with addressing the situation.  My impression was that she did not wish to upset the lady in the window seat.  But, her reassurance that an emergency evacuation was unlikely seemed to me to be an acknowledgment that there was a problem.

I was stuck.  Now that I had pointed out this situation, could I let it go unresolved?  Was this my responsibility to pursue, when a crew member did not seem overly concerned?

The answer came from the couple seated in front of the elderly woman.  They had heard the conversation and offered to change seats.  The flight attendant seemed relieved at this resolution.

Some thoughts on this vignette:

The emergency exit briefing procedure reminded me of the preop surgical checklist.  Both can be technically completed by reciting the prescribed list of questions.  However, each procedure achieves its goal of improved safety if all parties openly communicate.  Everyone has to be confident that safety concerns will be acknowledged and addressed.  The intent of the safety checklist must be satisfied.
While the flight attendant seemed to recognize my concern that the elderly passenger couldn't carry out the evacuation procedure, she seemed unsure of how to address this with the lady.  She didn't want to embarrass the lady by singling her out.  Perhaps a formal script would be useful: In case of an emergency, you will need to assist with evacuating the plane.  Are you capable of lifting the 40-pound door and throwing it out of the airplane? Pose this question to all exit row passengers, regardless of their age and size.  
I wondered if I am sufficiently open to hearing safety concerns in the OR.  If other members of the OR team see a problem, yet think I am not receptive to hearing their input (as was my impression of the flight attendant's approach to my concern), they will hesitate to speak up.  
Safety policies should be followed consistently.  Excuses that an adverse event is "extremely unlikely" undermine everyone's commitment to the safety process.